Provider First Line Business Practice Location Address:
291 S MAIN ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
SMITHFIELD
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84335-1902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
436-563-6211
Provider Business Practice Location Address Fax Number:
435-563-9481
Provider Enumeration Date:
08/15/2006